Provider Demographics
NPI:1184621401
Name:SIMON, GEOFFREY (MD)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:SIMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 765
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413
Mailing Address - Country:US
Mailing Address - Phone:315-737-1412
Mailing Address - Fax:315-738-9719
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-738-0647
Practice Address - Fax:315-738-9719
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY105165208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY025299OtherMVP
NY5328149OtherAETNA
NY10032749OtherCDPHP
NY00590047Medicaid
NY00590047Medicaid
NYD76907Medicare UPIN
NY5328149OtherAETNA